Notification of

Exit Form (DC)

Name of Retirement Scheme/Fund (The Fund)

Name of Employer/Sponsor/Founder

Section A - To be completed by employer

Member’s particulars (please complete in full)

Member Full Name

Member Number Date of Birth dd mm yy yy

Date of Employment dd mm yy yy Date of Joining Fund dd mm yy yy

Date of Exit dd mm yy yy Date of Last Contribution dd mm yy yy

Last Monthly Pensionable Salary KShs. (Per month)

Reason for exit (tick appropriate box)

Resignation Dismissal/Termination Retrenchment/Redundancy Death
Normal Retirement Ill Health Retirement Early Retirement Late Retirement

EMPLOYER’S DECLARATION
It is hereby confirmed and warranted that the information contained herein is correct. The Employer hereby
unconditionally absolves the Fund Trustees and Zamara as necessary and indemnifies and keeps indemnified the
Fund Trustees and Zamara from and against all and any loss, damage, costs and expenses which the beneficiaries, or
any other person whatsoever, may sustain or incur, either directly or indirectly as a result of Zamara, on behalf of the
Fund, relying on and using any information supplied by the Employer, specifically where the Employer has failed to
obtain the beneficiary’s signature on this notification.

Name of Authorised Officer:

Signature/Stamp: Date: dd mm yyyy

Section B - To be completed by member (please complete all sections)

Member’s particulars (please complete in full)

Please verify that the details contained in Section 1 as confirmed by your Employer are accurate. Also fill in your
contact details as below.
Residential and Postal address
Town County
KRA PIN Mobile No.
Email Address

Zamara Actuaries, Administrators & Consultants Limited O +254 (20) 4969 000
P.O. Box 52439 - 00200 Nairobi, 10th Floor, Landmark Plaza E benefits@zamara.co.ke
Argwings Kodhek Road, Opposite Nairobi Hospital W www.zamara.co.ke Actuaries | Administrators | Consultants | Insurance Brokers
Banking Details

If the benefit is to be paid directly to YOU by Zamara, please ensure that the banking details section below is
completed in full, (if applicable).

Please Note:
(i) Ensure that the bank account details supplied are in respect of your own account.
(ii) All cheques issued are ‘NOT TRANSFERABLE’ and must be deposited into the payee’s account

Account Name Account Number

Branch Code Name of Bank
Name of Branch

Section C - To be completed by member

Please read the document on options available to members on Exit before you fill in this section.
The document is available from the Human Resources Office or from the Fund Trustees;

MEMBER’S SIGNATURE & DISCHARGE

I ........................................................................................................................................................................................................... have read

the benefit options in respect of my benefits from the Fund and hereby select the option indicated below (tick box).

Options available on withdrawal from fund before retirement:

(i) Retain my full Retirement Account in the Fund

(ii) Access the Member Portion of my Retirement Account plus 50% of the Employer Portion of my Retirement
Account and retain 50% of the Employer Portion in the Fund
(iii) Access the Member Portion of my Retirement Account plus 50% of the Employer Portion of my Retirement
Account and transfer 50% of the Employer Portion to another approved retirement benefits scheme
(Please provide details of the other approved retirement benefits scheme below)
(iv) Transfer my full Retirement Account to another approved retirement benefits scheme
(Please provide details of the other approved retirement benefits scheme below)
(v) I wish to access a lower portion, (please indicate the amount and/or percentage you wish to access for us
to calculate your benefits)

Amount Percentage

Options available on retirement:

(i) Access one-third (1/3rd) of my Member Account as a one-off lump sum with the balance used to secure
a monthly pension/annuity or income draw down
(ii) Use the full Member Account or residual amount as appropriate] to secure a monthly pension/annuity or
income draw down
(iii) I wish to retain my funds and access them later
(iv) I wish to transfer my benefits to another approved plan
(v) I wish to access my full benefit as a one-off lumpsum (available only to provident arrangement or trivial
benefits)

If you choose to transfer out your benefit or secure an income draw down, provide the
following details:
Name of Scheme/Plan
Plan Provider
Pension Plan Bank Account No.
Contact Details
MEMBER’S SIGNATURE & DISCHARGE

I ...................................................................................................................................................................................... hereby confirm that:

(i) I have read the benefit options available in respect of my benefits from the Fund and confirm the selected benefit
payment options in respect of my benefit from the Fund as selected above;
(ii) Payment of my benefit as specified hereinabove represents full and final discharge of the Fund obligation to me
in respect of my benefits under the Fund other than any benefit that I have opted to preserve in the Fund;
I hereby confirm that this release and discharge shall bind my heirs and personal representatives;
(iii) Any retained benefits will be paid to me in accordance with the Fund Rules and prevailing legislation;
(iv) The details provided herein, in particular my contact and banking details are true and correct in every way;
(v) I understand the options available to me with regard to the payment of my benefits, including the withholding tax
implications and confirm that I am making an informed choice; and
(vi) I understand that failure to, or delay in, selecting and communicating my preferred option to Zamara or the
Employer’s Human Resources department will result in a delay of the payment of my benefit.

Signature: Date: dd mm yyyy

Witness: Date: dd mm yyyy

Attach a copy of your identification (ID or Passport) and a copy of your KRA PIN/iTax Certificate

Section D - Trustees’ Declaration

It is hereby confirmed and warranted that the information contained hereinabove including the information submitted
by the Employer and the member is correct and, in particular, that the member’s banking details provided above have
been confirmed as correct.

Name of Trustee 1:

Signature: Date: dd mm yyyy

Name of Trustee 2:

Signature: Date: dd mm yyyy

For and on behalf of the Trustees of:

COPYRIGHT:
Copyright in this material is expressly reserved and this form and all attachments (where applicable) remains the
exclusive property of Zamara Actuaries, Administrators & Consultants Limited. This form and all attachments (where
applicable) may not be copied, stored, retrieved or in any way reproduced without the express written permission
of Zamara Actuaries, Administrators & Consultants Limited. Breach of copyright is a serious offence and can lead to
litigation.